Chapter 15Chapter 15Diseases Resulting Diseases Resulting

from Fungi and Yeastsfrom Fungi and Yeasts

Andrews’ Diseases of the SkinAndrews’ Diseases of the Skin

Adam Wray, D.O.Adam Wray, D.O.

February 8, 2005February 8, 2005

Superficial mycosesSuperficial mycoses

► AKA dermatophytesAKA dermatophytes► Three genera: Three genera: Microsporum, Microsporum,

Trichophyton, EpidermophytonTrichophyton, Epidermophyton► Division into seven types (1)tinea Division into seven types (1)tinea

capitis, (2)tinea barbae, (3)tinea faciei, capitis, (2)tinea barbae, (3)tinea faciei, (4)tinea corporis, (5) tinea manus, (6) (4)tinea corporis, (5) tinea manus, (6) tinea pedis, (7) tinea cruris, tinea pedis, (7) tinea cruris, (8)onychomycosis(8)onychomycosis

Host factorsHost factors

► Immunosuppressed ptsImmunosuppressed pts► AIDS AIDS ► Genetic susceptibility may be related to types of Genetic susceptibility may be related to types of

keratin or degree/mix of cutaneous lipids keratin or degree/mix of cutaneous lipids produced produced

► Surface antigens-ABO system-one study of 108 Surface antigens-ABO system-one study of 108 culture proven dermatophytosis pts noted type A culture proven dermatophytosis pts noted type A blood prone to chronic diseaseblood prone to chronic disease

► Human steroid hormones can inhibit growth of Human steroid hormones can inhibit growth of dermatophytes (androgens like androstenedione)dermatophytes (androgens like androstenedione)

► One group believes this high susceptibility of One group believes this high susceptibility of Trichophyton rubrum & Epidermophyton Trichophyton rubrum & Epidermophyton floccosum floccosum to intrafollicular androstenedione is a to intrafollicular androstenedione is a reason why these species do not cause tinea reason why these species do not cause tinea capitiscapitis

ImidazolesImidazoles► Clotrimazole, miconazole, sulconazole, Clotrimazole, miconazole, sulconazole,

oxiconazole, and ketoconazoleoxiconazole, and ketoconazole► Mostly used for topical txMostly used for topical tx► Inhibit cytochrome P450 14-alpha-demethylase Inhibit cytochrome P450 14-alpha-demethylase

(an essential enzyme in ergosterol synthesis)(an essential enzyme in ergosterol synthesis)► Ketaconazole has wide spectrum against Ketaconazole has wide spectrum against

dermatophytes, yeasts, and some systemic dermatophytes, yeasts, and some systemic mycosesmycoses

► Ketaconazole has the potential for serious drug Ketaconazole has the potential for serious drug interactions and a higher incidence of interactions and a higher incidence of hepatotoxicity during long-term daily therapyhepatotoxicity during long-term daily therapy

AllylaminesAllylamines► Naftifine, terbinafine, butenafineNaftifine, terbinafine, butenafine► Inhibites squalene epoxydationInhibites squalene epoxydation► Terbinafine has less activity against Terbinafine has less activity against

CandidaCandida species in vitro studies then species in vitro studies then triazoles, but is effective clinicallytriazoles, but is effective clinically

► Terbinafine is ineffective in the oral tx of Terbinafine is ineffective in the oral tx of tinea versicolor but is effective topicallytinea versicolor but is effective topically

► Few drug interactions have been reportedFew drug interactions have been reported► Bioavailability is unchanged in foodBioavailability is unchanged in food► Hepatotoxicity, leukopenia, severe Hepatotoxicity, leukopenia, severe

exanthems, and taste disturbances exanthems, and taste disturbances uncommon, but should be monitored for uncommon, but should be monitored for clinically and by lab testing if continuous clinically and by lab testing if continuous dosing over 6 weeksdosing over 6 weeks

PolyenePolyene

►NystatinNystatin► Irreversibly binding to ergosterol-an Irreversibly binding to ergosterol-an

essential component of fungal cell essential component of fungal cell membranesmembranes

TriazolesTriazoles► Itraconazole, FluconazoleItraconazole, Fluconazole► Affect P450 systemAffect P450 system► Numerous drug interactions occurNumerous drug interactions occur► Need to know pt’s current medsNeed to know pt’s current meds► Broadest spectrum to dermatophytes Broadest spectrum to dermatophytes

and and Candida Candida species, and species, and Malassezia Malassezia furfurfurfur

► Itraconazole is fungistatic-food increases Itraconazole is fungistatic-food increases its absorption , antacids and gastric acid its absorption , antacids and gastric acid secretion suppressors produce erratic or secretion suppressors produce erratic or lowered absorptionlowered absorption

► Pulse dosing limits concern over lab Pulse dosing limits concern over lab abnormalitiesabnormalities

► Fluconazoles’s absorption is unaffected Fluconazoles’s absorption is unaffected by foodby food

Tinea CapitisTinea Capitis

► Occurs chiefly in schoolchildrenOccurs chiefly in schoolchildren► Boys more frequently than girls; except Boys more frequently than girls; except

epidemics caused by epidemics caused by Trichophyton Trichophyton tonsuranstonsurans where there is equal frequency where there is equal frequency

► Divided into inflammatory and Divided into inflammatory and noninflammatorynoninflammatory

► Tinea capitis can be caused by all Tinea capitis can be caused by all pathogenic dermatophytes except pathogenic dermatophytes except Epidermophyton floccosumEpidermophyton floccosum and and T. T. concentricumconcentricum

► In U.S. most caused by In U.S. most caused by T. tonsuransT. tonsurans

Noninflammatory Noninflammatory

► M. audouiniiM. audouinii infections present as the infections present as the classic form classic form

► Characterized by multiple scaly lesions Characterized by multiple scaly lesions (“gray-patch”), stubs of broken hair(“gray-patch”), stubs of broken hair

► Over past 30 yrs, Over past 30 yrs, M. audouinii M. audouinii infections are infections are being replaced by increasing numbers of being replaced by increasing numbers of “black-dot” ringworm, caused primarily by “black-dot” ringworm, caused primarily by T. tonsuransT. tonsurans and occasionally by and occasionally by T. T. violaceumviolaceum

► In the U.SIn the U.S. T. tonsurans . T. tonsurans is the most is the most common cause common cause

Noninflammatory Tinea Noninflammatory Tinea CapitisCapitis

►““Black dot” ringworm, caused by Black dot” ringworm, caused by T. T. tonsurans & tonsurans & occasionally occasionally T. violaceumT. violaceum presents as multiple areas of alopecia presents as multiple areas of alopecia studded with black dots representing studded with black dots representing infected hairs broken off at or below infected hairs broken off at or below the surface of the scalpthe surface of the scalp

►Black dot tineaBlack dot tinea

►Black dot ringworm caused by Black dot ringworm caused by Trichophyton tonsuransTrichophyton tonsurans

Inflammatory Inflammatory ► Usually caused by Usually caused by M. canisM. canis► Can be caused by Can be caused by T. mentagrophytes, T. T. mentagrophytes, T.

tonsurans, M. gypsem, or T. verrucosumtonsurans, M. gypsem, or T. verrucosum► M. canisM. canis begin as scaly, erythematous, begin as scaly, erythematous,

papular eruptions with loose and papular eruptions with loose and broken-off hairs, followed by varying broken-off hairs, followed by varying degrees of inflammationdegrees of inflammation

► A localized spot accompanied by A localized spot accompanied by pronounced swelling, with developing pronounced swelling, with developing bogginess and induration exuding pus bogginess and induration exuding pus develops-develops-kerion celsiikerion celsii A delayed type hypersensitivity reaction to A delayed type hypersensitivity reaction to

fungal elementsfungal elements► With extensive lesions fever, pain, and With extensive lesions fever, pain, and

regional lymphadenopathy may occurregional lymphadenopathy may occur

KerionKerion

► Kerion may be followed by scarring and Kerion may be followed by scarring and permanent alopecia in areas of permanent alopecia in areas of inflammation and suppurationinflammation and suppuration

► Systemic steroids for short periods will Systemic steroids for short periods will greatly diminish the inflammatory response greatly diminish the inflammatory response and reduce the risk of scarringand reduce the risk of scarring

► Kerion: inflammatory rxn of tinea capitis Kerion: inflammatory rxn of tinea capitis caused by caused by Microsporum canis or Microsporum canis or Trichophyton mentagrophytesTrichophyton mentagrophytes

►Kerion Kerion caused by caused by Microsporum Microsporum caniscanis

►Kerion: heavily crusted, hairless Kerion: heavily crusted, hairless plaqueplaque

►Permanent scarring alopecia post Permanent scarring alopecia post kerionkerion

►Kerion: Kerion: red, red, oozing, oozing, hairless hairless plaqueplaque

FavusFavus► Rare in the U.S.Rare in the U.S.► Most severe form of dermatophyte hair Most severe form of dermatophyte hair

infectioninfection► Most frequently cause by Most frequently cause by T. schoenleiniiT. schoenleinii► Hyphae and air spaces seen within hair shaftHyphae and air spaces seen within hair shaft► Bluish white fluorescence under Wood’s lightBluish white fluorescence under Wood’s light► Thick, yellow crusts composed of hyphae and Thick, yellow crusts composed of hyphae and

skin debris (‘scutula’)skin debris (‘scutula’)► Scarring alopecia may developScarring alopecia may develop

►Favus of scalp showing scutulaeFavus of scalp showing scutulae

Favus with scarring alopecia and Favus with scarring alopecia and scutulascutula

►Scarring after favus infectionScarring after favus infection

EtiologyEtiology

► Tinea capitis can be cause by any one Tinea capitis can be cause by any one of several species: of several species: T. tonsurans, M. T. tonsurans, M. audouinii audouinii (human to human)(human to human), and M. , and M. canis canis (animals to human)(animals to human)

► Endothrix types-Endothrix types-T. tonsuransT. tonsurans(black-dot (black-dot ringworm) and ringworm) and T. violaceumT. violaceum

► Ectothrix found on scalp are Ectothrix found on scalp are T. T. verrucosum & T. mentagrophytesverrucosum & T. mentagrophytes

DiagnosisDiagnosis

► Wood’s lightWood’s light Ultraviolet of 365 nm wavelength is obtained by Ultraviolet of 365 nm wavelength is obtained by

passing a beam through a Wood’s filter composed of passing a beam through a Wood’s filter composed of nickel oxide-containing glassnickel oxide-containing glass

A simple form is the 125-volt purple bulbA simple form is the 125-volt purple bulb► Fluorescent-positive infections are caused Fluorescent-positive infections are caused

by :by :T. T. sschoenleinii, M. choenleinii, M. ccanis, M. anis, M. aaudouinii, M. udouinii, M. ddistortum, M. istortum, M. fferrugineumerrugineum

► Hairs infected with Hairs infected with T. tonsurans & T. violaceum T. tonsurans & T. violaceum and others of endothrix do not fluoresceand others of endothrix do not fluoresce

► The fluorescent substance is pteridineThe fluorescent substance is pteridine

DiagnosisDiagnosis

► KOHKOH Two or three loose hairs are removedTwo or three loose hairs are removed Hairs are placed on slide with a drop of 10-Hairs are placed on slide with a drop of 10-

20% solution of KOH20% solution of KOH A cover slip is applied, specimen is warmed A cover slip is applied, specimen is warmed

until hairs are macerateduntil hairs are macerated Examine under low, then high powerExamine under low, then high power

► Scales or hairs cleared with it can still Scales or hairs cleared with it can still be culturedbe cultured

DTMDTM

► DTM contains cycloheximide to reduce DTM contains cycloheximide to reduce growth of contaminants and a colored pH growth of contaminants and a colored pH indicator to denote the alkali-producing indicator to denote the alkali-producing dermatophytesdermatophytes

► Some clinically relevant nondermatophyte Some clinically relevant nondermatophyte fungi are cycloheximide sensitive (fungi are cycloheximide sensitive (Candida Candida tropicalis, Scopulariopsis brevicaulis, tropicalis, Scopulariopsis brevicaulis, Cryptococcus neoformans, Cryptococcus neoformans, Pseudoallescheria boydii, Trichosporon Pseudoallescheria boydii, Trichosporon beigelii beigelii and and Aspergillus Aspergillus spp.)spp.)

►Ectothrix type in Ectothrix type in Microsporum canis-Microsporum canis-note small spores around hair shaftnote small spores around hair shaft

► Endothrix spores in hair with Endothrix spores in hair with Trichophyton Trichophyton tonsuranstonsurans

►Endothrix inEndothrix in T. scoenleinii T. scoenleinii showing showing characteristic bubbles of aircharacteristic bubbles of air

►Endothrix infection, (low-power KOH Endothrix infection, (low-power KOH mount): arthroconidia noted within mount): arthroconidia noted within hair shafthair shaft

►Endothrix infection (high-power KOH Endothrix infection (high-power KOH mount) showing total hair shaft mount) showing total hair shaft involvementinvolvement

T. tonsuransT. tonsurans

►This microoraganism grows slowly in This microoraganism grows slowly in culture to produce a granular or culture to produce a granular or powdery yellow to red, brown, or buff powdery yellow to red, brown, or buff colonycolony

►Crater formation with radial grooves Crater formation with radial grooves may be producedmay be produced

►Microconidia may be seen regularlyMicroconidia may be seen regularly►Dx confirmed by the fact that cultures Dx confirmed by the fact that cultures

grow poorly or not at all without grow poorly or not at all without thiaminethiamine

T. mentagrophytesT. mentagrophytes

► Culture growth is velvety or granular or Culture growth is velvety or granular or fluffy, flat or furrowed, light buff, white, or fluffy, flat or furrowed, light buff, white, or sometimes pinksometimes pink

► Back of the culture can vary from buff to Back of the culture can vary from buff to dark reddark red

► Round microconidia borne laterally and in Round microconidia borne laterally and in clusters confirm dx within 2 weeksclusters confirm dx within 2 weeks

► Spirals are sometimes presentSpirals are sometimes present► Macroconidia may be seenMacroconidia may be seen

T. verrucosumT. verrucosum

►Growth is slow and cannot be Growth is slow and cannot be observed well for at least 3 weeksobserved well for at least 3 weeks

►Colony is compact, glassy, velvety, , Colony is compact, glassy, velvety, , heaped or furrowed, and usually white, heaped or furrowed, and usually white, but may be yellow or graybut may be yellow or gray

►Chlamydospores are present in early Chlamydospores are present in early culturescultures

►Microconidia may be seenMicroconidia may be seen

M. audouiniiM. audouinii

► Gross appearance shows a slowly growing, Gross appearance shows a slowly growing, matted, velvety, light brown colonymatted, velvety, light brown colony

► Back of which is reddish brown to orangeBack of which is reddish brown to orange► Under microscope a few large multiseptate Under microscope a few large multiseptate

macroconidia (macroaleuriospores) are seenmacroconidia (macroaleuriospores) are seen► Microconidia (microaleuriospores) in a Microconidia (microaleuriospores) in a

lateral position on hyphae are clavatelateral position on hyphae are clavate► Racquet mycelium, chlamydospores, and Racquet mycelium, chlamydospores, and

pectinate hyphae are seen sometimespectinate hyphae are seen sometimes

M. canisM. canis

► Culture shows profuse, fuzzy, cottony, aerial Culture shows profuse, fuzzy, cottony, aerial mycelia tending to become powdery in the mycelia tending to become powdery in the centercenter

► Color is buff to light brownColor is buff to light brown► Back of colony is lemon to orange-yellowBack of colony is lemon to orange-yellow► Numerous spindle-shaped multiseptate Numerous spindle-shaped multiseptate

microconidia and thick-walled macroconidia microconidia and thick-walled macroconidia are presentare present

► Clavate microconidia are found along with Clavate microconidia are found along with chlamydospores and pectinate bodieschlamydospores and pectinate bodies

TreatmentTreatment► Griseofulvin of ultramicronized form, 10 mg/kg/day, Griseofulvin of ultramicronized form, 10 mg/kg/day,

is the daily dose recommended for childrenis the daily dose recommended for children► Grifulvin V is the only oral suspension available for Grifulvin V is the only oral suspension available for

children unable to swallow tablets-dose is 20 children unable to swallow tablets-dose is 20 mg/kg/daymg/kg/day

► Tx should continue for 2-4 months, or for at least 2 Tx should continue for 2-4 months, or for at least 2 weeks after a negative microscopic and culture weeks after a negative microscopic and culture examinations are obtainedexaminations are obtained

► Griseofulvin does not primarily affect the delayed Griseofulvin does not primarily affect the delayed type hypersensitivity reaction responsible for the type hypersensitivity reaction responsible for the inflammation in kerioninflammation in kerion

► For this, systemic steroids, to minimize scarring, can For this, systemic steroids, to minimize scarring, can be given simultaneouslybe given simultaneously

Tinea BarbaeTinea Barbae

► AKA Tinea sycosis, barber’s itchAKA Tinea sycosis, barber’s itch► UncommonUncommon► Occurs chiefly among those in Occurs chiefly among those in

agricultureagriculture► Involvement is mostly one-sided on Involvement is mostly one-sided on

neck or faceneck or face► Two clinical types are: deep, nodular, Two clinical types are: deep, nodular,

suppurative lesions; and superficial , suppurative lesions; and superficial , crusted, partially bald patches with crusted, partially bald patches with folliculitisfolliculitis

Tinea BarbaeTinea Barbae

►Superficial crusted type Superficial crusted type mild pustular folliculitis with broken-off mild pustular folliculitis with broken-off

hairs (hairs (T. violaceum) T. violaceum) or without broken-off or without broken-off hairs (hairs (T. rubrum)T. rubrum)

Affected hairs are loose, dry, and brittleAffected hairs are loose, dry, and brittle When extracted bulb appears intactWhen extracted bulb appears intact

Tinea BarbaeTinea Barbae

► Deep typeDeep type Caused mostly by Caused mostly by T. mentagrophytes T. mentagrophytes or or T. T.

verrucosumverrucosum Swellings are usually confluent and form Swellings are usually confluent and form

diffuse boggy infiltrates with abscessesdiffuse boggy infiltrates with abscesses Pus may be expressed Pus may be expressed Lesions are limited to one part of face or Lesions are limited to one part of face or

neck in menneck in men

Diagnosis-Tinea BarbaeDiagnosis-Tinea Barbae

►ClinicalClinical►Confirmed by microscopic findings and Confirmed by microscopic findings and

by standard culture techniques by standard culture techniques ►Rarely, Rarely, Epidermophyton floccosumEpidermophyton floccosum

may cause widespread verrucous may cause widespread verrucous lesions known as lesions known as verrucous verrucous epidermophytosisepidermophytosis

► Verrucous epidermophytosis from Verrucous epidermophytosis from Epidermphyton Epidermphyton floccosumfloccosum

► Complete resolution after 48 days of griseofulvinComplete resolution after 48 days of griseofulvin

Differential DiagnosisDifferential Diagnosis

►Sycosis vulgaris-lesions are pustules Sycosis vulgaris-lesions are pustules and papules, pierced in the center by a and papules, pierced in the center by a hair, which is loose and easily hair, which is loose and easily extracted after suppuration has extracted after suppuration has occurredoccurred

►Contact dermatitisContact dermatitis►Herpes infectionsHerpes infections

►Tinea barbae-Tinea barbae-Trichophyton mentagorphytesTrichophyton mentagorphytes

Treatment-Tinea BarbaeTreatment-Tinea Barbae

►Oral antifungals are requiredOral antifungals are required►Topical agents as adjunctive Topical agents as adjunctive

therapytherapy►Micronized or ultramicronized Micronized or ultramicronized

griseofulvin orally: dosage of 500–griseofulvin orally: dosage of 500–1000 mg or 350-700 mg 1000 mg or 350-700 mg respectively respectively

►Tx usually for 4-6 weeksTx usually for 4-6 weeks

Treatment-Tinea BarbaeTreatment-Tinea Barbae

► Other orals that have been effective: Other orals that have been effective: ketoconazole, fluconazole, itraconazole, and ketoconazole, fluconazole, itraconazole, and terbinafineterbinafine

► Topical antifungals should be applied from the Topical antifungals should be applied from the beginning of txbeginning of tx

► Affected parts should be bathed thoroughly in Affected parts should be bathed thoroughly in soap and watersoap and water

► Healthy areas that are not epilated may be Healthy areas that are not epilated may be shaved or clippedshaved or clipped

► When kerion is present a short course of When kerion is present a short course of systemic steriod therapy may help reduce systemic steriod therapy may help reduce inflammation and risk of scarringinflammation and risk of scarring

Tinea FacieiTinea Faciei

► Fungal infection of the face (apart from Fungal infection of the face (apart from the beard)the beard)

► Must have high index of suspicionMust have high index of suspicion Mistaken for seb derm, contact derm, lupus, Mistaken for seb derm, contact derm, lupus,

or photosensitive dermatosisor photosensitive dermatosis► Erythematous, slightly scaling, indistinct Erythematous, slightly scaling, indistinct

borders are usually seenborders are usually seen► Usually caused by Usually caused by T. rubrum. T. T. rubrum. T.

mentagrophytes, or M. canismentagrophytes, or M. canis

► Tinea faciei Tinea faciei ((Microsporum Microsporum caniscanis) in a child) in a child

►Tinea Tinea corporis corporis involving involving the face the face (tinea (tinea faciei)faciei)

TreatmentTreatment

► Topical antifungalsTopical antifungals► Oral griseofulvin administered for 2-4 Oral griseofulvin administered for 2-4

weeks, as well as fluconazole, itraconazole, weeks, as well as fluconazole, itraconazole, or terbinafine are all effective particularly in or terbinafine are all effective particularly in combination with topical therapycombination with topical therapy

Tinea Corporis(Tinea Tinea Corporis(Tinea Circinata)Circinata)

► All superficial dermatophyte infections of All superficial dermatophyte infections of the skin except the scalp, beard, face, the skin except the scalp, beard, face, hands, feet, and groinhands, feet, and groin

► Sites of predilection are neck, upper and Sites of predilection are neck, upper and lower extremities, and trunklower extremities, and trunk

► Characterized by one or more circular, Characterized by one or more circular, sharply circumcsribed, slightly sharply circumcsribed, slightly erythematous, dry, scaly, usually erythematous, dry, scaly, usually hypopigmented patcheshypopigmented patches

► Tinea corporis in a Tinea corporis in a child, caused by child, caused by Microsporum canisMicrosporum canis

Tinea CorporisTinea Corporis

► In some cases concentric circles form In some cases concentric circles form rings in one another, making intricate rings in one another, making intricate patterns (tinea imbricata)patterns (tinea imbricata)

► Widespread tinea corporis may be the Widespread tinea corporis may be the presenting sign of AIDSpresenting sign of AIDS

► Tinea corporis Tinea corporis ((Trichophyton Trichophyton rubrum)rubrum)

► Note sharp margins Note sharp margins and central clearingand central clearing

►Tinea corporis: large gyrate plaque Tinea corporis: large gyrate plaque with advancing border, perhaps with advancing border, perhaps worsened by diaperingworsened by diapering

HistopathologyHistopathology

►Better ways to make diagnosisBetter ways to make diagnosis►But if compact orthokeratosis is found But if compact orthokeratosis is found

in a section, a search for fungal in a section, a search for fungal hyphae should be performedhyphae should be performed

►This is diagnosticThis is diagnostic

Etiology-Tinea CorporisEtiology-Tinea Corporis

►Microsporum canis, T. rubrum, T. Microsporum canis, T. rubrum, T. mentagrophytesmentagrophytes-most common-most common

►T. rubrum T. rubrum is is the most common is is the most common dermatophyte in the U.S. and worldwidedermatophyte in the U.S. and worldwide

►T. tonsuransT. tonsurans has experienced a has experienced a dramatic rise as a cause of tinea dramatic rise as a cause of tinea corporis as it has for tinea capitiscorporis as it has for tinea capitis

► In children, In children, M. canisM. canis is the cause of the is the cause of the “moist” type of tinea circinata“moist” type of tinea circinata

EpidemiologyEpidemiology

► Tinea corporis is frequently seen in children-Tinea corporis is frequently seen in children-particularly those exposed to animals with particularly those exposed to animals with ringworm(ringworm(M. canis)M. canis), especially , especially CATSCATS, dogs , dogs and less commonly, horses and cattleand less commonly, horses and cattle

► In adults excessive perspiration is the most In adults excessive perspiration is the most common factorcommon factor Personal hx or close contact with tinea capitis or Personal hx or close contact with tinea capitis or

tinea pedis is another important factortinea pedis is another important factor

► Incidence is especially high in hot, humid Incidence is especially high in hot, humid areas of the worldareas of the world

Treatment-Tinea CorporisTreatment-Tinea Corporis► When tinea corporis is caused by When tinea corporis is caused by T. tonsurans, M. T. tonsurans, M.

canis, T. mentagrophytes, or T. rubrum canis, T. mentagrophytes, or T. rubrum , , griseofulvin, terbinafine, itraconazole, and griseofulvin, terbinafine, itraconazole, and fluconazole are all effectivefluconazole are all effective

► The ultra-micronized form may be used at a dose of The ultra-micronized form may be used at a dose of 350-750 mg once/day for 4-6 weeks350-750 mg once/day for 4-6 weeks

► This dose may be increased to twice daily if neededThis dose may be increased to twice daily if needed► Terbinafine, itraconazole, and fluconazole are Terbinafine, itraconazole, and fluconazole are

effectiveeffective► Terbinafine at 250 mg/day for two weeksTerbinafine at 250 mg/day for two weeks► Itraconazole 200 mg B.I.D. for one weekItraconazole 200 mg B.I.D. for one week► Fluconazole 150 mg once/week for 4 weeksFluconazole 150 mg once/week for 4 weeks

Treatment(cont)Treatment(cont)

►When only 1-2 patches occur, When only 1-2 patches occur, topical tx is effectivetopical tx is effective

►Most are between 2-4 weeks with Most are between 2-4 weeks with twice daily usetwice daily use

►Econazole, ketaconazole, Econazole, ketaconazole, oxiconazole, and terbinafine may oxiconazole, and terbinafine may be used once dailybe used once daily

►With terbinafine the course can be With terbinafine the course can be shortened to 1 weekshortened to 1 week

Treatment Treatment ► Creams are more effective than lotionsCreams are more effective than lotions► Sulconazole may be less irritating in Sulconazole may be less irritating in

folded areasfolded areas► Castellani paint (which is colorless if Castellani paint (which is colorless if

made without fuchin) is very effectivemade without fuchin) is very effective► Salicylic acid 3% -5%, or half-strength Salicylic acid 3% -5%, or half-strength

Whitfield’s ointment, both standbys 30 Whitfield’s ointment, both standbys 30 yrs ago, are little used todayyrs ago, are little used today

► Addition of a low-potency steroid cream Addition of a low-potency steroid cream during the initial 3-5 days of therapy will during the initial 3-5 days of therapy will decrease irritation rapidly without decrease irritation rapidly without compromising the effectiveness of the compromising the effectiveness of the antifungalantifungal

Other Forms of Tinea Other Forms of Tinea CorporisCorporis

► Trichophytic Granuloma or Perifollicular Trichophytic Granuloma or Perifollicular Granuloma or Majocchi’s Granuloma or Granuloma or Majocchi’s Granuloma or Tinea IncognitoTinea Incognito

► A deep, pustular type of tinea circinata A deep, pustular type of tinea circinata resembling a carbuncle or kerion observed resembling a carbuncle or kerion observed on the glabrous skinon the glabrous skin

► A circumscribed, annular, raised, crusty, and A circumscribed, annular, raised, crusty, and boggy granulomaboggy granuloma

► Follicles are distended with viscid purulent Follicles are distended with viscid purulent materialmaterial

► Tichophyton Tichophyton mentagrophytesmentagrophytes infection on lower infection on lower leg of American leg of American soldier in Vietnamsoldier in Vietnam

►Majocchi’s granuloma H&E pale blue-Majocchi’s granuloma H&E pale blue-staining fungal hyphae within hair shaftstaining fungal hyphae within hair shaft

► Majocchi’s granuloma: PAS reveals multiple Majocchi’s granuloma: PAS reveals multiple organisms that have replaced a fragment of organisms that have replaced a fragment of hair shaft embedded in a sea of neutrophilshair shaft embedded in a sea of neutrophils

Tinea Imbricata (Tokelau)Tinea Imbricata (Tokelau)► Superficial fungal infection limited to Superficial fungal infection limited to

southwest Polynesia, Melanesia, southwest Polynesia, Melanesia, Southeast Asia, India, and Central Southeast Asia, India, and Central AmericaAmerica

► Characterized by concentric rings of Characterized by concentric rings of scales forming extensive patches with scales forming extensive patches with polycyclic borderspolycyclic borders

► Small macular patch splits in center and Small macular patch splits in center and forms large, flaky scales attached at the forms large, flaky scales attached at the peripheryperiphery

► Resultant ring spreads peripherally and Resultant ring spreads peripherally and another brownish macule appears in the another brownish macule appears in the center and undergoes the process againcenter and undergoes the process again

Tinea ImbricataTinea Imbricata► When fully developed the eruption is characterized When fully developed the eruption is characterized

by concentrically arranged rings or parallel by concentrically arranged rings or parallel undulating lines of scales overlapping each other undulating lines of scales overlapping each other like shingles on a roof (imbrex means shingle)like shingles on a roof (imbrex means shingle)

► Causative fungus is Causative fungus is T. concentricumT. concentricum► TOC is griseofulvin- in same form as for tinea TOC is griseofulvin- in same form as for tinea

corporiscorporis► Other options are terbinafine, fluconazole, and Other options are terbinafine, fluconazole, and

itraconazoleitraconazole► Several courses of therapy may be neededSeveral courses of therapy may be needed► May need to remove pt from hot, humid May need to remove pt from hot, humid

environmentenvironment

►Tinea imbricata in New Guinea nativeTinea imbricata in New Guinea native

►Tinea imbricata: concentric rings of Tinea imbricata: concentric rings of scale caused by scale caused by T. concentricumT. concentricum

Tinea CrurisTinea Cruris► AKA jock itchAKA jock itch► Most common in menMost common in men► On upper and inner thighsOn upper and inner thighs► Begins as a small erythematous and Begins as a small erythematous and

scaling or vesicular and crusted patch scaling or vesicular and crusted patch ► Spreads peripherally and partly clears in Spreads peripherally and partly clears in

the centerthe center► Penoscrotal fold or sides of scrotum are Penoscrotal fold or sides of scrotum are

seldom involved; penis not involvedseldom involved; penis not involved

►Tinea cruris in a manTinea cruris in a man

►Tinea cruris in a womanTinea cruris in a woman

Etiology-Tinea CrurisEtiology-Tinea Cruris

►T. mentagrophytes T. mentagrophytes && E. floccosum & T. E. floccosum & T. rubrumrubrum usual cause usual cause

►Frequently associated with tinea pedis Frequently associated with tinea pedis b/c of contaminated clothing b/c of contaminated clothing

►Heat and high humidityHeat and high humidity►Tight Tight jockey shortsjockey shorts!!

TreatmentTreatment

► Reduce perspiration and enhance Reduce perspiration and enhance evaporation from crural area evaporation from crural area

► Keep as dry as possible by wearing Keep as dry as possible by wearing loose underclothing loose underclothing

► Plain talcum powder or antifungal Plain talcum powder or antifungal powderspowders

► Specific topical and oral tx is same as Specific topical and oral tx is same as that described under tinea corporisthat described under tinea corporis

►Tinea in diapered areaTinea in diapered area

Tinea PedisTinea Pedis► AKA athlete’s footAKA athlete’s foot► Most common fungal disease(by far)Most common fungal disease(by far)► Primary lesions often are macerated Primary lesions often are macerated

with occasional vesiculation, and with occasional vesiculation, and fissures between the toesfissures between the toes

► Extreme pruritusExtreme pruritus

► Tinea pedis showing interdigital Tinea pedis showing interdigital scalpingscalping

► T. mentagrophytesT. mentagrophytes

► Interdigital scaling with vesiculation Interdigital scaling with vesiculation caused by T. mentagrophytescaused by T. mentagrophytes

►DermatophytosDermatophytosis of the solesis of the soles

►Trichophyton Trichophyton mantagrophytemantagrophytess

►Acute Acute vesiculobullous vesiculobullous eruption on eruption on sole caused by sole caused by Trichophyton Trichophyton mentagrophytementagrophytess

TP-TP-Trichophyton rubrumTrichophyton rubrum

► T. rubrumT. rubrum causes the causes the majority of cases majority of cases

► Produces a relatively Produces a relatively noninflammatory type noninflammatory type of dermatophytosis of dermatophytosis characterized by a dull characterized by a dull erythema and erythema and pronounced scaling pronounced scaling involving the entire involving the entire sole and sides of feetsole and sides of feet

► Producing a moccasin Producing a moccasin or sandal appearanceor sandal appearance

► Tinea pedis and Tinea pedis and onychomycosis in onychomycosis in father/son pair.father/son pair.

► Father shows classic Father shows classic moccasin moccasin distribution of tinea distribution of tinea pedis and son shows pedis and son shows distal subungual distal subungual onychomycosisonychomycosis

Tinea manusTinea manus

► Tinea infection of Tinea infection of hands that is dry, hands that is dry, scaly, and scaly, and erythematous may erythematous may occuroccur

► Suggestive of infection Suggestive of infection with with T. rubrumT. rubrum

► Other areas are Other areas are frequently affected at frequently affected at the same timethe same time

►Trichophyton rubrum Trichophyton rubrum infectionsinfections

Differential diagnosisDifferential diagnosis

► Allergic contact or irritant dermatitis-Allergic contact or irritant dermatitis-especially occupationalespecially occupational

► PompholyxPompholyx► Atopic dermatitisAtopic dermatitis► PsoriasisPsoriasis► Lamellar dyshidrosisLamellar dyshidrosis► Eczematoid or dyshidrotic lesions of Eczematoid or dyshidrotic lesions of

unknown cause on hands should prompt a unknown cause on hands should prompt a search for clinical evidence of search for clinical evidence of dermatophytosis of feet etc.dermatophytosis of feet etc.

► Fungus filaments under KOH mountFungus filaments under KOH mount

►Mosaic fungusMosaic fungus

Prophylaxis Prophylaxis

► Hyperhidrosis is a predisposing factorHyperhidrosis is a predisposing factor► Dry toes after bathingDry toes after bathing► Tolnaftate powder or Zeasorb medicated Tolnaftate powder or Zeasorb medicated

powders for feetpowders for feet► Plain talc, cornstartch, or rice powder may Plain talc, cornstartch, or rice powder may

be dusted into socks and shoes to keep feet be dusted into socks and shoes to keep feet drydry

TreatmentTreatment

► Topical antifungalsTopical antifungals► With significant maceration wet dressings With significant maceration wet dressings

or soaks with solutions such as aluminum or soaks with solutions such as aluminum acetate, one part to 20 parts of wateracetate, one part to 20 parts of water

► Anti-inflammatory effects of Anti-inflammatory effects of corticosteroids are markedly beneficialcorticosteroids are markedly beneficial

► Topical antibiotic ointments effective Topical antibiotic ointments effective against gram-negative organisms against gram-negative organisms (gentamicin), in tx of the moist type of (gentamicin), in tx of the moist type of interdigital lesionsinterdigital lesions

► In ulcerative type of gram-neg toe web In ulcerative type of gram-neg toe web infections, systemic floxins are neededinfections, systemic floxins are needed

TxTx

► Keratolytic agents, such as salicylic Keratolytic agents, such as salicylic acid, lactic acid lotions, and Carmol are acid, lactic acid lotions, and Carmol are therapeutic when fungus is protected by therapeutic when fungus is protected by a thick layer of overlying skin (ie soles)a thick layer of overlying skin (ie soles)

► Griseofulvin is only effective against Griseofulvin is only effective against dermatophytesdermatophytes

► When infection is caused by When infection is caused by T. T. mentagrophytesmentagrophytes griseofulvin does not griseofulvin does not decrease inflammatory rxdecrease inflammatory rx

Tx-dosesTx-doses

► Griseovulvin in ultramicronized particles Griseovulvin in ultramicronized particles taken orally in doses of 350-750 mg dailytaken orally in doses of 350-750 mg daily

► Dosage for children is 10 mg/kg/dayDosage for children is 10 mg/kg/day► Period of tx depends on response Period of tx depends on response ► Repeated KOH scrapings and culture should Repeated KOH scrapings and culture should

be negbe neg► Recommended adult doses for newer Recommended adult doses for newer

agents: terbinafine, 250 mg/day for 2 agents: terbinafine, 250 mg/day for 2 weeks; itraconazole, 200 mg twice daily for weeks; itraconazole, 200 mg twice daily for 1 week; fluconazole, 150 mg once weekly 1 week; fluconazole, 150 mg once weekly for 4 weeksfor 4 weeks

Onychomycosis(Tinea Onychomycosis(Tinea Unguium)Unguium)

► Onychomycosis encompasses both Onychomycosis encompasses both dermatophyte and nondermatophyte nail dermatophyte and nondermatophyte nail infectionsinfections

► Represents up to 30% of diagnosed Represents up to 30% of diagnosed superficial fungal infectionssuperficial fungal infections

► Etiologic agents are: Etiologic agents are: Epidermophyton, Epidermophyton, Microsporum, and Trichophyton Microsporum, and Trichophyton fungifungi

OnychomycosisOnychomycosis

► Four classic types:Four classic types:► 1.) distal subungual onychomycosis: 1.) distal subungual onychomycosis:

primarily involves distal nail bed and primarily involves distal nail bed and hyponychium, with secondary involvement hyponychium, with secondary involvement of underside of nail plate of fingernails and of underside of nail plate of fingernails and toenailstoenails

►Onychomycosis caused by Onychomycosis caused by Trichophyton rubrumTrichophyton rubrum

Trichophyton Trichophyton mentagrophytesmentagrophytes

► 2.) white superficial 2.) white superficial onychomycosis(leukonyconychomycosis(leukonychia trichophytica):this is hia trichophytica):this is an invasion of the toenail an invasion of the toenail plate on the surface of plate on the surface of the nailthe nail

► It is produced by It is produced by T.mentagrophytes, T.mentagrophytes, species of species of Cephalosporium and Cephalosporium and Aspergillus, and Fusarium Aspergillus, and Fusarium oxysporum oxysporum fungusfungus

OnychomycosisOnychomycosis

► 3.) Proximal subungual onychomycosis: 3.) Proximal subungual onychomycosis: involves the nail plate mainly from proximal involves the nail plate mainly from proximal nail foldnail fold

► It is produced by It is produced by T. rubrum & T. megniniiT. rubrum & T. megninii and and may be an indication of HIV infectionmay be an indication of HIV infection

► 4.) Candida onychomycosis involves all the nail 4.) Candida onychomycosis involves all the nail plate; it is due to plate; it is due to Candida albicansCandida albicans and is seen and is seen in pts with chronic mucocuataneous candidiasis in pts with chronic mucocuataneous candidiasis Associated paronychiaAssociated paronychia Adjacent cuticle is pink, swollen, and tenderAdjacent cuticle is pink, swollen, and tender Fingernails > toenailsFingernails > toenails

►Onychomycosis caused by Onychomycosis caused by Candida Candida albicansalbicans in mucocutaneous in mucocutaneous candidiasiscandidiasis

OnychomycosisOnychomycosis

► Onychomycosis caused Onychomycosis caused by by T. rubrum T. rubrum is usually is usually a deep infectiona deep infection

► Disease usually starts Disease usually starts at distal corner of nail at distal corner of nail and involves the and involves the junction of nail and its junction of nail and its bedbed

► First a yellowish First a yellowish discoloration occurs, discoloration occurs, which may spread until which may spread until entire nail is affectedentire nail is affected

► Beneath discoloration Beneath discoloration nail plate becomes nail plate becomes loose from nail bedloose from nail bed

► Gradually entire nail becomes brittle and Gradually entire nail becomes brittle and separated from its bed due to piling up of separated from its bed due to piling up of keratin subungually keratin subungually

► Nail may break off, leaving an undermined Nail may break off, leaving an undermined remnant that is black and yellow from dead nail remnant that is black and yellow from dead nail and fungi that are presentand fungi that are present

►A: Distal subungal, onchomycosis A: Distal subungal, onchomycosis occurring simulataneously with occurring simulataneously with superficial white onchmycosissuperficial white onchmycosis

►B: Superficial white onchomycosisB: Superficial white onchomycosis

DifferentialDifferential

► Allergic contact dermatitisAllergic contact dermatitis► PsoriasisPsoriasis► Lichen planusLichen planus► 20 nail dystrophy20 nail dystrophy► Darier’s diseaseDarier’s disease► Reiter’s diseaseReiter’s disease► Norwegian scabiesNorwegian scabies► Nondermatophyte onychomycosisNondermatophyte onychomycosis

TreatmentTreatment

► PO terbinafine, fluconazole, and PO terbinafine, fluconazole, and itraconazoleitraconazole

► Griseofulvin continued until nails are Griseofulvin continued until nails are clinically normalclinically normal

► Low success rates 15-30% for toenails Low success rates 15-30% for toenails and 50-70% for fingernailsand 50-70% for fingernails

► Griseofulvin does not tx nail disease Griseofulvin does not tx nail disease caused by candidacaused by candida

► 3% thymol in EtOH3% thymol in EtOH

CandidiasisCandidiasis

► Candida Candida proliferates in both budding and proliferates in both budding and mycelial forms in outer layers of the mycelial forms in outer layers of the stratum corneum where horny cells are stratum corneum where horny cells are desquamatingdesquamating

► It does not attack hair, rarely involves nail, It does not attack hair, rarely involves nail, and is incapable of breaking up the stratum and is incapable of breaking up the stratum corneumcorneum

► It is largely an opportunisitic organismIt is largely an opportunisitic organism► Moisture promotes its growthMoisture promotes its growth

Lip cornersLip corners Body foldsBody folds

DiagnosisDiagnosis

► Demonstration of the pathogenic yeast Demonstration of the pathogenic yeast C. albicansC. albicans establishes the diagnosis establishes the diagnosis

► Under microscope KOH prep may show Under microscope KOH prep may show spores and pseudomyceliumspores and pseudomycelium

► Culture on Sabouraud’s glucose agar Culture on Sabouraud’s glucose agar shows a growth of creamy, grayish, shows a growth of creamy, grayish, moist colonies in about 4 days moist colonies in about 4 days

► In time colonies form small, root-like In time colonies form small, root-like penetrations into agarpenetrations into agar

►Mycelium and spores of Mycelium and spores of Candida albicansCandida albicans

CandidiasisCandidiasis

► KOH mount from infant with thrush showing KOH mount from infant with thrush showing pseudohyphae and yeast formspseudohyphae and yeast forms

Topical Anticandidal AgentsTopical Anticandidal Agents

► These include, but are not limited to: These include, but are not limited to: clotrimazole (Lotrimin, Mycelex), econazole clotrimazole (Lotrimin, Mycelex), econazole (Spectazole), ketaconazole (Nizoral), (Spectazole), ketaconazole (Nizoral), miconazole (MonistatDerm Lotion, Micatin), miconazole (MonistatDerm Lotion, Micatin), oxiconazole (Oxistat), sulconazole (Exelderm), oxiconazole (Oxistat), sulconazole (Exelderm), naftifine (Naftin), terconazole (vaginal naftifine (Naftin), terconazole (vaginal candidiasis only), cicloprox olamine (Loprox), candidiasis only), cicloprox olamine (Loprox), butenafine (Mentax), nystatin, and topical butenafine (Mentax), nystatin, and topical amphotericin B lotionamphotericin B lotion

► Terbinafine has been reported to be less Terbinafine has been reported to be less active against active against Candida Candida species by some species by some authorsauthors

Oral Candidiasis (Thrush)Oral Candidiasis (Thrush)

► Newborn infection may be acquired from Newborn infection may be acquired from contact with vaginal tract of mothercontact with vaginal tract of mother

► Grayish white membranous plaques are Grayish white membranous plaques are found on surfacefound on surface

► Base of plaques are moist, reddish, and Base of plaques are moist, reddish, and maceratedmacerated

► Diaper areas is especially susceptible to Diaper areas is especially susceptible to thisthis

► Most of intertriginous areas and even Most of intertriginous areas and even exposed skin may be involvedexposed skin may be involved

► Frequently infection extends onto Frequently infection extends onto angles of the mouth to form angles of the mouth to form perleche(seen in elderly, debilitated, perleche(seen in elderly, debilitated, and malnourished pts, and diabetics)and malnourished pts, and diabetics)

► It is often the first manifestation of AIDSIt is often the first manifestation of AIDS► Is present in nearly 100% of all Is present in nearly 100% of all

untreated pts with full-blown AIDSuntreated pts with full-blown AIDS► ““Thrush” in an adult with no known Thrush” in an adult with no known

predisposing factors warrants a search predisposing factors warrants a search for other evidence of infection with HIV, for other evidence of infection with HIV, such as lymphadenopathy, leukopenia, such as lymphadenopathy, leukopenia, or HIV antibodies in serumor HIV antibodies in serum

Oral candidiasis (Thrush)Oral candidiasis (Thrush)

►Thrush with extension to vermilion borderThrush with extension to vermilion border

TxTx

► Babies with thrush may be allowed to Babies with thrush may be allowed to suck on a clotrimazole suppository suck on a clotrimazole suppository inserted into the slit tip of a pacifier four inserted into the slit tip of a pacifier four times a day for 2-3 daystimes a day for 2-3 days

► An adult can let tablets of clotrimazole An adult can let tablets of clotrimazole or Mycelex troches dissolve in the or Mycelex troches dissolve in the mouthmouth

► Fluconazole, 100-200 mg/day for 5-10 Fluconazole, 100-200 mg/day for 5-10 days with doubling the dose if it fails, or days with doubling the dose if it fails, or itraconazole, 200 mg daily for 5-10 days itraconazole, 200 mg daily for 5-10 days with doubling the dose if it fails-both are with doubling the dose if it fails-both are available in liquid formsavailable in liquid forms

PerlechePerleche

► AKA angular cheilitisAKA angular cheilitis► Maceration with transverse fissuring of Maceration with transverse fissuring of

oral commissuresoral commissures► Soft, pinhead-sized papules may appearSoft, pinhead-sized papules may appear► Involvement is bilateral-usuallyInvolvement is bilateral-usually

PerlechePerleche

PerlechePerleche► Analogous to intertrigo elsewhereAnalogous to intertrigo elsewhere► Similar changes may be seen in Similar changes may be seen in

riboflavin deficiency, and iron deficiency riboflavin deficiency, and iron deficiency anemiaanemia

► Identical fissuring occurs in persons with Identical fissuring occurs in persons with malocclusion caused by ill-fitting malocclusion caused by ill-fitting dentures and in the aged whom atrophy dentures and in the aged whom atrophy of alveolar ridges has occurredof alveolar ridges has occurred

► Seen in children who drool, lick their Seen in children who drool, lick their lips, or suck their thumblips, or suck their thumb

TxTx► If due to If due to C. albicansC. albicans anticandidal anticandidal

creams and lotionscreams and lotions► Glycemic control in diabetesGlycemic control in diabetes► Antibiotic topical meds are used when a Antibiotic topical meds are used when a

bacterial; infection is presentbacterial; infection is present► If due to vertical shortening of lower If due to vertical shortening of lower

third of the face, dental or oral surgical third of the face, dental or oral surgical intervention may helpintervention may help

► Injection of collagen into depressed Injection of collagen into depressed sulcus at the oral commissure may be sulcus at the oral commissure may be helpfulhelpful

► Vytone!!Vytone!!

Candidal VulvovaginitisCandidal Vulvovaginitis► Pruritus, irritation, and extreme burningPruritus, irritation, and extreme burning► Labia may be erythemtous, moist, and Labia may be erythemtous, moist, and

macerated and cervix hyperemic, macerated and cervix hyperemic, swollen, and eroded, showing small swollen, and eroded, showing small vesicles on its surfacevesicles on its surface

► Vaginal discharge is not usually profuse Vaginal discharge is not usually profuse but is frequently thick and tenaciousbut is frequently thick and tenacious

► May develop during pregnancy, in May develop during pregnancy, in diabetes, or secondary to therapy with a diabetes, or secondary to therapy with a broad- spectrum antibioticbroad- spectrum antibiotic

► Recurrent vulvovaginal candidiasis has Recurrent vulvovaginal candidiasis has been associated with long-term been associated with long-term tamoxifen txtamoxifen tx

Candidal VulvovaginitisCandidal Vulvovaginitis► Candidal balanitis may be present in an Candidal balanitis may be present in an

uncircumcised sexual partneruncircumcised sexual partner► If not recognized, repeated reinfection of a partner If not recognized, repeated reinfection of a partner

may occurmay occur► Diagnosis is by clinical symptoms and findings as Diagnosis is by clinical symptoms and findings as

well as demonstration of fungus via KOH well as demonstration of fungus via KOH microscopic exam & culturemicroscopic exam & culture

► Tx is frustrating & disappointing due to recurrencesTx is frustrating & disappointing due to recurrences► Oral fluconazole 150 mg times 1 dose; Fluconazole, Oral fluconazole 150 mg times 1 dose; Fluconazole,

100mg/day for 5-7 days, itraconazole, 200 mg/day 100mg/day for 5-7 days, itraconazole, 200 mg/day for 2-3 days..other optionsfor 2-3 days..other options

TxTx

►Topical options include miconizole Topical options include miconizole (Monistat cream), nystatin vaginal (Monistat cream), nystatin vaginal suppositories or tablets (Mycostatin), suppositories or tablets (Mycostatin), or clotrimazole (Gyne-Lotrimin or or clotrimazole (Gyne-Lotrimin or Mycelex G) vaginal tablets inserted Mycelex G) vaginal tablets inserted once daily for 7 daysonce daily for 7 days

Candidal IntertrigoCandidal Intertrigo

► Pinkish intertriginous moist patches are Pinkish intertriginous moist patches are surrounded by a thin, overhanging surrounded by a thin, overhanging fringe of somewhat macerated fringe of somewhat macerated epidermis (“collarette” scale)epidermis (“collarette” scale)

► May resemble tinea cruris, but usually May resemble tinea cruris, but usually there is less scaliness and a greater there is less scaliness and a greater tendency to fissuringtendency to fissuring

► Topical anticandidal preparations are Topical anticandidal preparations are usually effectiveusually effective

► Recurrence is commonRecurrence is common

Pseudo Diaper RashPseudo Diaper Rash► In infants, In infants, C. albicans C. albicans infection may start infection may start

in perianal region and spread over entire in perianal region and spread over entire areaarea

► Dermatits is enhanced by maceration Dermatits is enhanced by maceration produced by wet diapersproduced by wet diapers

► Diaper friction may contribute to skin Diaper friction may contribute to skin irritation and compromised function of irritation and compromised function of stratum corneumstratum corneum

► Suspected by finding involvement of folds Suspected by finding involvement of folds and occurrence of many small and occurrence of many small erythematous desquamating “satellite” or erythematous desquamating “satellite” or “daughter” lesions scattered around edges“daughter” lesions scattered around edges

Congenital Cutaneous Congenital Cutaneous CandidiasisCandidiasis

► Infection of an infant during passage Infection of an infant during passage through birth canalthrough birth canal

► Eruption usually noted within first few Eruption usually noted within first few hrs of deliveryhrs of delivery

► Erythematous macules progress to thin-Erythematous macules progress to thin-walled pustules, which rupture, dry, and walled pustules, which rupture, dry, and desquamate within a weekdesquamate within a week

► Lesions are usually widespread, Lesions are usually widespread, involving trunk, neck, and head, at times involving trunk, neck, and head, at times palms and soles, including nail foldspalms and soles, including nail folds

► Oral cavity and diaper area are sparedOral cavity and diaper area are spared

Congenital Cutaneous Congenital Cutaneous CandidiasisCandidiasis

► Differential dx: listeriosis, syphilis, Differential dx: listeriosis, syphilis, staphylococcal and herpes infections, ETN, staphylococcal and herpes infections, ETN, transient neonatal pustular melanosis, transient neonatal pustular melanosis, miliaria rubra , drug eruption, congenital miliaria rubra , drug eruption, congenital icthyosiform erythroderma (neonatal icthyosiform erythroderma (neonatal pustular disorders)pustular disorders)

► If suspected early amniotic fluid, placenta, If suspected early amniotic fluid, placenta, and cord should be examined for evidence and cord should be examined for evidence of infectionof infection

► Infants with disease limited to skin have Infants with disease limited to skin have favorable outcomesfavorable outcomes

CCCCCC► Disseminated infection is suggested by Disseminated infection is suggested by

(1) bw <1500g (2) evidence of (1) bw <1500g (2) evidence of respiratory distress or labs indicating respiratory distress or labs indicating neonatal sepsis (3) tx with broad-neonatal sepsis (3) tx with broad-spectrum antibiotics (4) extensive spectrum antibiotics (4) extensive instrumentation during delivery or instrumentation during delivery or invasive procedures in neonatal period invasive procedures in neonatal period (5) positive systemic cultures, or (6) (5) positive systemic cultures, or (6) evidence of an altered immune responseevidence of an altered immune response

► Infants with congenital cutaneous Infants with congenital cutaneous candidiasis with any of these 6 criteria candidiasis with any of these 6 criteria would be considered for systemic would be considered for systemic antifungal therapyantifungal therapy

Perianal CandidiasisPerianal Candidiasis► Frequently entire GI tract is involvedFrequently entire GI tract is involved► Can be precipitated by oral antibiotic Can be precipitated by oral antibiotic

therapytherapy► Perianal dermatitis with erythema, oozing, Perianal dermatitis with erythema, oozing,

and maceration is presentand maceration is present► Psychogenic etiology is more common than Psychogenic etiology is more common than

is candidiasisis candidiasis► Differential dx: psoriasis, seborrheic Differential dx: psoriasis, seborrheic

dermatitis, streptococcal and staphylococcal dermatitis, streptococcal and staphylococcal infections, contact dermatits, and infections, contact dermatits, and extramammary Paget’s diseaseextramammary Paget’s disease

► Fungicides, meticulous cleansing of perianal Fungicides, meticulous cleansing of perianal region after bowel movements, topical region after bowel movements, topical corticosteroids and antipruritics (Atarax)corticosteroids and antipruritics (Atarax)

Candidal ParonychiaCandidal Paronychia► Cushionlike thickening of paronychial Cushionlike thickening of paronychial

tissue, slow erosion of lateral borders of tissue, slow erosion of lateral borders of nails, gradual thickening and brownish nails, gradual thickening and brownish discoloration of nail plates, and discoloration of nail plates, and development of pronounced transverse development of pronounced transverse ridgesridges

► Frequently only one nailFrequently only one nail► A secondary mixed bacterial infection can A secondary mixed bacterial infection can

occur with those who frequently have occur with those who frequently have hands in water or who handle moist hands in water or who handle moist objects; cooks, dishwashers, bartenders, objects; cooks, dishwashers, bartenders, nurses, canners, etcnurses, canners, etc

CPCP► Manicuring nails sometimes is responsible Manicuring nails sometimes is responsible

for mechanical or chemical injuries for mechanical or chemical injuries leading to infectionleading to infection

► Ingrown toenails with chronic paronychia Ingrown toenails with chronic paronychia ► Seen in pts with diabetesSeen in pts with diabetes► Avoid chronic moisture exposure; get Avoid chronic moisture exposure; get

diabetes under controldiabetes under control► Oral fluconazole once weekly or pulse Oral fluconazole once weekly or pulse

dose itraconazole should be effectivedose itraconazole should be effective► Topical therapy should continue for 2-3 Topical therapy should continue for 2-3

months to prevent recurrencemonths to prevent recurrence

Erosia Interdigitalis Erosia Interdigitalis BlastomyceticaBlastomycetica

► Oval-shaped area of macerated white skin Oval-shaped area of macerated white skin on web between and extending onto sides on web between and extending onto sides of fingersof fingers

► With progression macerated skin peels off, With progression macerated skin peels off, leaving painful, raw,denuded area leaving painful, raw,denuded area surrounded by a collar of overhanging white surrounded by a collar of overhanging white epidermisepidermis

► Nearly always affects third webNearly always affects third web► Moisture beneath rings macerates skin and Moisture beneath rings macerates skin and

predisposes to infectionpredisposes to infection► Also seen in diabetics, those who do Also seen in diabetics, those who do

housework, launderers, and others exposed housework, launderers, and others exposed to macerating effects of water and strong to macerating effects of water and strong alkalisalkalis

Chronic Mucocutaneous Chronic Mucocutaneous CandidiasisCandidiasis

► A heterogeneous group of pts whose A heterogeneous group of pts whose infection with infection with Candida Candida is chronic but is chronic but superficialsuperficial

► Onset before age 6Onset before age 6► Onset in adult life may herald the Onset in adult life may herald the

occurrence of thymomaoccurrence of thymoma► When inherited an endocrinopathy is often When inherited an endocrinopathy is often

foundfound► Most cases have well-defined limited Most cases have well-defined limited

defects of cell-immunitydefects of cell-immunity► Oral lesions are diffuse and perleche and Oral lesions are diffuse and perleche and

lip fissures are commonlip fissures are common

Systemic CandidiasisSystemic Candidiasis► High risk pts: pts with malignancies, High risk pts: pts with malignancies,

AIDS, transplant pts requiring AIDS, transplant pts requiring immunosuppressive drugs, pts on oral immunosuppressive drugs, pts on oral cortisone, pts who have had multiple cortisone, pts who have had multiple surgical operations especially cardiac, pts surgical operations especially cardiac, pts with indwelling catheters, and heroin with indwelling catheters, and heroin addictsaddicts

► Initial sign is varied: FUO, pulmonary Initial sign is varied: FUO, pulmonary infiltrates, GI bleeding, endocarditis, infiltrates, GI bleeding, endocarditis, renal failure, meningitis, osteomyelitis, renal failure, meningitis, osteomyelitis, endophthalmitis, peritonitis, or a endophthalmitis, peritonitis, or a disseminated maculopapular eruptiondisseminated maculopapular eruption

SCSC

► Cutaneous findings are erythematous Cutaneous findings are erythematous macules that become papular, pustular, macules that become papular, pustular, and hemorrhagic, and may progress to and hemorrhagic, and may progress to necrotic, ulcerating lesions resembling necrotic, ulcerating lesions resembling ecthyma gangrenosumecthyma gangrenosum

► Deep abscesses may occurDeep abscesses may occur► Trunk and extremities are usual sites of Trunk and extremities are usual sites of

involvementinvolvement► Proximal muscle tenderness is a Proximal muscle tenderness is a

common findingcommon finding

SCSC

► If candida is cultured within the first week of If candida is cultured within the first week of life there is a high rate of systemic diseaselife there is a high rate of systemic disease

► There is a 50% chance of systemic disease if There is a 50% chance of systemic disease if 1 or more cultures is positive1 or more cultures is positive

► Mortality has declined from 80% in the Mortality has declined from 80% in the 1970’s to 40% in the 1990’s because of 1970’s to 40% in the 1990’s because of early empiric antifungals and better early empiric antifungals and better prophylaxisprophylaxis

THE ENDTHE END

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